KEMENTERIAN HUKUM DAN HAM R I

KANTOR WILAYAH KALIMANTAN TENGAH

LEMBAGA PEMASYARAKATAN KLAS II B PANGKALAN BUN
JL. Jenderal Sudirman No. 51 Pangkalan Bun Kode Pos : 74111
Telepon / Fax : (0532) 21193, 24125; email : 013.01.406714.lppbun@gmail.com

BERITA ACARA
PEMERIKSAAN KESEHATAN TAHANAN

Nomor :...................................................

Pada hari ini ......................................tanggal.......................................jam................................kami

Sebagai dokter / paramedis Lapas telah memeriksa kesehatan seorang tahanan.

1. Nama : ......................................................................................
2. Tempat / tgl lahir, umur : ......................................................................................
3. Jenis Kelamin : ......................................................................................
4. Kebangsaan : ......................................................................................
5. Agama : ......................................................................................
6. Pekerjaan : ......................................................................................
7. Alamat : ......................................................................................
8. Mulai ditahan : ......................................................................................
9. Pejabat yang menahan : ......................................................................................
10. Perkara / Pasal : ......................................................................................

Dengan hasil periksaaan sebagai berikut :

- Keadaan umum : .................................................................. ( keadaaan gizi,kulit )

- Tensi : ........................................................................ ( tekanan darah )

- COR : .............................................. ( keadaan jantung dan denyutnya )

...............................................................................................

- Pulmo : .......................................................... ( keadaan paru – parunya )

..............................................................................................

- Abdomen : ................................................................... ( keadaan perutnya )

.............................................................................................

- Extremitas : ............................................... ( anggota gerak atas dan bawah )

..................................................................................................

- Kesimpulan : .................................................................................................

.................................................................................................

Demikian Berita Acara ini dibuat sebenarnya dengan mengingat sumpah jabatan.

Pangkalan Bun, ................... 2019

Tanda tangan Dokter Lembaga Pemasyarakatan
tahanan ybs

............................................ dr. Happy Muthia Devi

NIP. 19890106 2017122 001